Abstract
Many hematologic malignancies require hematopoietic cell transplantation (HCT) during their course of treatment. Total body irradiation (TBI) has an important role in patients undergoing HCT. TBI induces immunosuppression to prevent the rejection of donor marrow. TBI is also used to eradicate malignant cells in sanctuary organs that are not reached by chemotherapy drugs. However, combined with chemotherapy, TBI is associated with significant toxicities. Targeted TBI has been shown to be able to reduce doses to normal organs, which predicts for reduced toxicities compared with standard TBI. Since the first total marrow irradiation (TMI) patient using intensity-modulated radiation therapy (IMRT) on Helical TomoTherapy was treated in 2005, many studies have been conducted and published. In this article, we review the practical aspects of targeted TBI implementation starting from patient positioning, immobilization, CT simulation, target delineation, plan optimization, dosimetry comparison, and quality assurance to treatment delivery. Recommendations on practical implementation to deliver targeted TBI are made with the intent to improve the planning and treatment process and to establish consistent and comparable treatment standards among institutions.
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References
Ferrebee JW, Thomas ED. Factors affecting the survival of transplanted tissues. Am J Med Sci. 1958;235:369–86.
Schenken LL, Hagemann RF. Time/dose relationships in experimental radiation cataractogenesis. Radiology. 1975;117:193–8.
Van Dyk J, Keane TJ, Kan S, Rider WD, Fryer CJ. Radiation pneumonitis following large single dose irradiation: a re-evaluation based on absolute dose to lung. Int J Radiat Oncol Biol Phys. 1981;7:461–7.
Blaise D, Maraninchi D, Archimbaud E, Reiffers J, Devergie A, Jouet JP, Milpied N, Attal M, Michallet M, Ifrah N. Allogeneic bone marrow transplantation for acute myeloid leukemia in first remission: a randomized trial of a busulfan-cytoxan versus cytoxan-total body irradiation as preparative regimen: a report from the Group d’Etudes de la Greffe de Moelle Osseuse. Blood. 1992;79:2578–82.
Thomas BC, Stanhope R, Plowman PN, Leiper AD. Growth following single fraction and fractionated total body irradiation for bone marrow transplantation. Eur J Pediatr. 1993;152:888–92.
Leiper AD. Late effects of total body irradiation. Arch Dis Child. 1995;72:382–5.
Shank B. The balancing act: pneumonitis vs. relapse in cytoreductive regimens containing total body irradiation. Int J Radiat Oncol Biol Phys. 1996;36:261–2.
Curtis RE, Rowlings PA, Deeg HJ, Shriner DA, Socie G, Travis LB, Horowitz MM, Witherspoon RP, Hoover RN, Sobocinski KA, Fraumeni JFJ, Boice JDJ. Solid cancers after bone marrow transplantation. N Engl J Med. 1997;336:897–904.
Ringden O, Remberger M, Ruutu T, Nikoskelainen J, Volin L, Vindelov L, Parkkali T, Lenhoff S, Sallerfors B, Mellander L, Ljungman P, Jacobsen N. Increased risk of chronic graft-versus-host disease, obstructive bronchiolitis, and alopecia with busulfan versus total body irradiation: long-term results of a randomized trial in allogeneic marrow recipients with leukemia. Nordic Bone Marrow Transplantation Group. Blood. 1999;93:2196–201.
Socie G, Clift RA, Blaise D, Devergie A, Ringden O, Martin PJ, Remberger M, Deeg HJ, Ruutu T, Michallet M, Sullivan KM, Chevret S. Busulfan plus cyclophosphamide compared with total-body irradiation plus cyclophosphamide before marrow transplantation for myeloid leukemia: long-term follow-up of 4 randomized studies. Blood. 2001;98:3569–74.
Della Volpe A, Ferreri AJM, Annaloro C, Mangili P, Rosso A, Calandrino R, Villa E, Lambertenghi-Deliliers G, Fiorino C. Lethal pulmonary complications significantly correlate with individually assessed mean lung dose in patients with hematologic malignancies treated with total body irradiation. Int J Radiat Oncol Biol Phys. 2002;52:483–8.
Hasegawa W, Pond GR, Rifkind JT, Messner HA, Lau A, Daly AS, Kiss TL, Kotchetkova N, Galal A, Lipton JH. Long-term follow-up of secondary malignancies in adults after allogeneic bone marrow transplantation. Bone Marrow Transplant. 2005;35:51–5.
Bolling T, Kreuziger DC, Ernst I, Elsayed H, Willich N. Retrospective, monocentric analysis of late effects after total body irradiation (TBI) in adults. Strahlenther Onkol. 2011;187:311–5.
Wong JYC, Liu A, Schultheiss T, et al. Targeted total marrow irradiation using three-dimensional image-guided tomographic intensity-modulated radiation therapy: an alternative to standard total body irradiation. Biol Blood Marrow Transplant. 2006;12:306–15.
McCutchen KW, Watkins JM, Eberts P, Terwilliger LE, Ashenafi MS, Jenrette JM. Helical tomotherapy for total lymphoid irradiation. Radiat Med. 2008 Dec;26(10):622–6.
Stein A, Palmer J, Tsai NC, Al Malki MM, Aldoss I, Ali H, Aribi A, Farol L, Karanes C, Khaled S, Liu A, O'Donnell M, Parker P, Pawlowska A, Pullarkat V, Radany E, Rosenthal J, Sahebi F, Salhotra A, Sanchez JF, Schultheiss T, Spielberger R, Thomas SH, Snyder D, Nakamura R, Marcucci G, Forman SJ, Wong J. Phase I trial of total marrow and lymphoid irradiation transplantation conditioning in patients with relapsed/refractory acute leukemia. Biol Blood Marrow Transplant. 2017 Apr;23(4):618–24.
Springer A, Hammer J, Winkler E, Track C, Huppert R, Böhm A, Kasparu H, Weltermann A, Aschauer G, Petzer AL, Putz E, Altenburger A, Gruber R, Moser K, Wiesauer K, Geinitz H. Total body irradiation with volumetric modulated arc therapy: dosimetric data and first clinical experience. Radiat Oncol. 2016 Mar 22;11:46.
Sun R, Cuenca X, Itti R, Nguyen Quoc S, Vernant JP, Mazeron JJ, Jenny C, Chea M. First French experiences of total body irradiations using helical TomoTherapy. Cancer Radiother. 2017 Aug;21(5):365–72.
Bao Z, Zhao H, Wang D, Gong J, Zhong Y, Xiong Y, Deng D, Xie C, Liu A, Wang X, Liu H. Feasibility of a novel dose fractionation strategy in TMI/TMLI. Radiat Oncol. 2018 Dec 17;13(1):248.
Cherpak A, Monajemi T, Chytyk-Praznik K, Mulroy L. Energy-dependent OAR sparing and dose conformity for total marrow irradiation of obese patients. J Appl Clin Med Phys. 2018 Sep;19(5):532–8.
Lin SC, Hsieh PY, Shueng PW, Tien HJ, Wang LY, Hsieh CH. Total marrow irradiation as part of autologous stem cell transplantation for Asian patients with multiple myeloma. Biomed Res Int. 2013;2013:321762.
Fogliata A, Cozzi L, Clivio A, et al. Preclinical assessment of volumetric modulated arc therapy for total marrow irradiation. Int J Radiat Oncol Biol Phys. 2011;80:628–36.
Mancosu P, Navarria P, Castagna L, et al. Interplay effects between dose distribution quality and positioning accuracy in total marrow irradiation with volumetric modulated arc therapy. Med Phys. 2013;111713(1–7):40.
Corvò R, Zeverino M, Vagge S, Agostinelli S, Barra S, Taccini G, Van Lint MT, Frassoni F, Bacigalupo A. Helical tomotherapy targeting total bone marrow after total body irradiation for patients with relapsed acute leukemia undergoing an allogeneic stem cell transplant. Radiother Oncol. 2011 Mar;98(3):382–6.
Schultheiss TE, Wong J, Liu A, Olivera G, Somlo G. Image-guided total marrow and total lymphatic irradiation using helical tomotherapy. Int J Radiat Oncol Biol Phys. 2007;67:1259–67.
Shueng PW, Lin SC, Chong NS, Lee HY, Tien HJ, Wu LJ, Chen CA, Lee JJ, Hsieh CH. Total marrow irradiation with helical tomotherapy for bone marrow transplantation of multiple myeloma: first experience in Asia. Technol Cancer Res Treat. 2009 Feb;8(1):29–38.
Wilkie JR, Tiryaki H, Smith BD, Roeske JC, Radosevich JA, Aydogan B. Feasibility study for linac-based intensity modulated total marrow irradiation. Med Phys. 2008;35:5609–18.
Jiang B, Dai J, Zhang Y, Zhang K. Feasibility study of a novel rotational and translational method for linac-based intensity modulated total marrow irradiation. Technol Cancer Res Treat. 2012;11(3):237–47.
Jiang Z, Jia J, Yue C, Pang Y, Liu Z, Ouyang L, Li H, Zhang J, Wen T, Li J, Li Z, Wang Y, Xiao Y, Xiao H. Haploidentical hematopoietic SCT using helical tomotherapy for total-body irradiation and targeted dose boost in patients with high-risk/refractory acute lymphoblastic leukemia. Bone Marrow Transplant. 2018;53(4):438–48.
Mancosu P, Navarria P, Castagna L, Reggiori G, Stravato A, Gaudino A, Sarina B, Tomatis S, Scorsetti M. Plan robustness in field junction region from arcs with different patient orientation in total marrow irradiation with VMAT. Phys Med. 2015;31(7):677–82.
Lou X, Xia TY, Chen H. Improved clinical outcome after total marrow irradiation conditioning stem cell transplantation for hematologic malignancies. In: Wong J, Hui SK, editors. Total marrow irradiation. New York: Springer; 2020.
Aydogan B, Yeginer M, Kavak GO, Fan J, Radosevich JA, Gwe-Ya K. Total marrow irradiation with RapidArc volumetric arc therapy. Int J Radiat Oncol Biol Phys. 2011;81:592–9.
Han C, Schultheisss TE, Wong JYC. Dosimetric study of volumetric modulated arc therapy fields for total marrow irradiation. Radiother Oncol. 2012;102:315–20.
Patel P, Aydogan B, Koshy M, Mahmud D, Oh A, Saraf SL, Quigley JG, Khan I, Sweiss K, Mahmud N, Peace DJ, DeMasi V, Awan AM, Weichselbaum RR, Rondelli D. Combination of linear accelerator-based intensity-modulated total marrow irradiation and myeloablative fludarabine/busulfan: a phase I study. Biol Blood Marrow Transplant. 2014;20(12):2034–41.
Rosenthal J, Wong J, Stein A, Qian D, Hitt D, Naeem H, Dagis A, Thomas SH, Forman S. Phase 1/2 trial of total marrow and lymph node irradiation to augment reduced-intensity transplantation for advanced hematologic malignancies. Blood. 2011;117(1):309–15.
Jensen LG, Stiller T, Wong JYC, Palmer J, Stein A, Rosenthal J. Total marrow lymphoid irradiation/fludarabine/melphalan conditioning for allogeneic hematopoietic cell transplantation. Biol Blood Marrow Transplant. 2018;24(2):301–7.
Hui SK, Verneris MR, Higgins P, Gerbi B, Weigel B, Baker SK, Fraser C, Tomblyn M, Dusenbery K. Helical tomotherapy targeting total bone marrow - first clinical experience at the University of Minnesota. Acta Oncol. 2007;46(2):250–5.
Miften M, Olch A, Mihailidis D, Moran J, Pawlicki T, Molineu A, Li H, Wijesooriya K, Shi J, Xia P, Papanikolaou N, Low DA. Tolerance limits and methodologies for IMRT measurement-based verification QA: Recommendations of AAPM Task Group No. 218. Med Phys. 2018;45(4):e53–83.
Mancosu P, Navarria P, Reggiori G, Cozzi L, Fogliata A, Gaudino A, Lobefalo F, Paganini L, Palumbo V, Sarina B, Stravato A, Castagna L, Tomatis S, Scorsetti M. In-vivo dosimetry with Gafchromic films for multi-isocentric VMAT irradiation of total marrow lymph-nodes: a feasibility study. Radiat Oncol. 2015;10:86.
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Liu, A., Han, C., Neylon, J. (2020). Implementation of Targeted Total Body Irradiation as a Bone Marrow Transplant Conditioning Regimen: A Review. In: Wong, J., Hui, S. (eds) Total Marrow Irradiation. Springer, Cham. https://doi.org/10.1007/978-3-030-38692-4_2
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DOI: https://doi.org/10.1007/978-3-030-38692-4_2
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